Active NPI
Jonelle Wallace, APRN, NP-C
- Nurse Practitioner
- Columbia, MD
National Provider Identifier
1417642364
On this page
Key facts
NPPES NPI Registry- Primary specialty
- Nurse Practitioner
- License
- 11314
- Practice address
- 10175 Little Patuxent Pkwy
Columbia, MD 21044-2655 - Phone
- (800) 328-5979
- NPI assigned
- Apr 6, 2023
- Last updated
- Apr 6, 2023
- Sex
- Female
- Sole proprietor
- No
NPPES NPI Registry
Registry information is reported by the provider to CMS and is not verified. About this source
Specialties & licenses 1
| Specialty (taxonomy) | Code | License | State | Primary |
|---|---|---|---|---|
| Nurse Practitioner | 363L00000X | 11314 | CT | Primary |
Addresses
Primary practice location
10175 Little Patuxent Pkwy
Columbia, MD 21044-2655
Mailing address
PO Box 1459
Minneapolis, MN 55440-1459
Medicare participation
Medicare enrollment files- Medicare fee-for-service enrollment
- Not listed in the public Medicare enrollment file
National Provider Directory
National Provider Directory- Medicare enrollment (NPD)
- Not enrolled
State licenses
| License | State | Type | Specialty |
|---|---|---|---|
| 11314 | CT | MD | Nurse Practitioner |
NPI Registry JSON
The complete NPPES record for this NPI in the NPI Registry API format.
{
"created_epoch": "1680739200000",
"enumeration_type": "NPI-1",
"last_updated_epoch": "1680739200000",
"number": "1417642364",
"addresses": [
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "MAILING",
"address_type": "DOM",
"address_1": "PO BOX 1459",
"city": "MINNEAPOLIS",
"state": "MN",
"postal_code": "554401459"
},
{
"country_code": "US",
"country_name": "United States",
"address_purpose": "LOCATION",
"address_type": "DOM",
"address_1": "10175 LITTLE PATUXENT PKWY",
"city": "COLUMBIA",
"state": "MD",
"postal_code": "210442655",
"telephone_number": "800-328-5979"
}
],
"practiceLocations": [],
"basic": {
"last_name": "WALLACE",
"first_name": "JONELLE",
"credential": "APRN, NP-C",
"sole_proprietor": "NO",
"sex": "F",
"enumeration_date": "2023-04-06",
"last_updated": "2023-04-06",
"certification_date": "2023-04-05",
"status": "A"
},
"taxonomies": [
{
"code": "363L00000X",
"taxonomy_group": "",
"desc": "Nurse Practitioner",
"state": "CT",
"license": "11314",
"primary": true
}
],
"identifiers": [],
"endpoints": [],
"other_names": []
}Other providers in Columbia, MD
Sources for this page
- NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 6, 2023; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
- National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.